Cardiology Coding Alert

Reporting 99363, 99364, or G0250 with these inpatient E/Ms will trigger a denial.

Medicare doesn’t pay separately for anticoagulant management codes 99363 and 99364, but that doesn’t mean these codes can escape Correct Coding Initiative (CCI) attention, as CCI version 22.1 proves.

Don’t Pair Anticoagulation and Observation Codes

On April 1, CCI enacted the following bundle: When the physician performs just about any hospital E/M for a patient, you cannot report any of the following codes in addition to the E/M:

• 99363, Anticoagulant management for an outpatient taking warfarin, physician review and interpretation of International Normalized Ratio (INR) testing, patient instructions, dosage adjustment (as needed), and ordering of additional tests; initial 90 days of therapy (must include a minimum of 8 INR measurements)
• 99364, … each subsequent 90 days of therapy (must include a minimum of 3 INR measurements) 
• G0250, Physician review, interpretation, and patient management of home INR testing for patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; testing not occurring more frequently than once a week; billing units of service include 4 tests.

These edits have a modifier indicator of 0, meaning you can never report the codes together for the same patient during the same encounter.

These are the E/M codes CCI says you may not report 99363, 99364, and G0250 with:

• 99217, Observation care discharge day management…
• 99218-99220, Initial observation care, per day, for the evaluation and management of a patient which requires these 3 key components …
• 99221-99223, Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components …
• 99224-99226, Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components …
• 99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components …

Additional bundles prevent you from reporting anticoagulation services with critical care services coded with 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and 99292 (… each additional 30 minutes [List separately in addition to code for primary service]).

Interpretation: When in the hospital, the providers review and convey any lab results during the time spent with the patients at the bedside or on the patient floor. You would not report anticoagulation testing codes separately from a hospital E/M, explains Suzan (Berman) Hauptman, MPM, CPC, CEMC, CEDC, medical coding director at Acusis, LLC, in Pittsburgh, Pa.

From a CPT^® perspective, it’s also worth noting that 99363 and 99364 each cover 90 days of outpatient therapy and G0250 covers four home tests with no more than one per week. So the intent of those codes is not to cover review of testing performed on a hospital patient.

CCI Also Makes Sure You Don’t Report INR at NF

CCI 22.1 also creates edits for 99363, 99364, and G0250 with nursing facility (NF) E/Ms:

• 99304-99306, Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components ...
• 99307-99310, Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components …
• 99315-99316, Nursing facility discharge day management …
• 99318, Evaluation and management of a patient involving an annual nursing facility assessment, which requires these 3 key components…

These edits also have a modifier indicator of 0, meaning you can never report them for the same patient during the same encounter.

Interpretation: INR and anticoagulation management “is included during the time and work involved in those patient visits. The results are part of the chart and easily reviewable,” Hauptman says.

Final tip: These edits are in line with CPT^® guidelines with 99363 and 99364: “These services are outpatient services only. When anticoagulation therapy is initiated or continued in the inpatient or observation setting, a new period begins after discharge and is reported with 99364. Do not report 99363-99364 with 99217-99239, 99291-99292, 99304-99318, 99471-99480 or other code(s) for physician review, interpretation, and patient management of home INR testing for a patient with mechanical heart valve(s).”

And as mentioned earlier, Medicare does not pay separately for 99363 and 99364, giving them status B (bundled) on the Medicare Physician Fee Schedule. Code G0250 has status R, meaning coverage is restricted to certain unusual circumstances.